Infection prevention and control policy template

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated, (Reg 12(2)(h) (infection control))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

Infection prevention and control sits squarely within Regulation 12(2)(h). The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections is issued by the Secretary of State under Section 21 of the Health and Social Care Act 2008. Although the Code itself is not statute, providers must have regard to it, and the Care Quality Commission takes the Code into account in registration and inspection. The Code is operationally enforceable via Regulations 12 (safe care and treatment), 15 (premises and equipment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Code sets out ten compliance criteria covering: systems to manage IPC; clean and appropriate environment; antimicrobial stewardship; service-user information; prompt identification of people at risk of infection; care-worker awareness and responsibility (including contractors and volunteers); isolation facilities; laboratory access; care policies; and staff health and wellbeing. The current version of the Code was last updated by the Department of Health and Social Care on 13 December 2022.

3. Scope

This policy applies to all employees, contractors, volunteers, and external parties who deliver, support, or oversee any regulated activity at . It covers every clinical and clinical-adjacent environment (consulting rooms, theatres, wards, recovery, decontamination rooms, mobile delivery, vehicle interiors where patients are transported), every clinical procedure (invasive, non-invasive, point-of-care), and every shared building service (laundry, waste, ventilation, water systems).

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

• Registered Manager: accountable for the IPC system operating across every site. Reviews any IPC breach, outbreak, or audit finding above a threshold. Signs off the annual IPC report.
• Nominated Individual: holds provider-side accountability for IPC.
• Infection Prevention and Control Lead (named individual): the day-to-day IPC authority. Operates the IPC audit programme, surfaces breach patterns, declares an outbreak per the Code's outbreak criteria, coordinates the response. Holds the IPC training to Level 3 or equivalent.
• Decontamination Lead (where dental, surgical, endoscopy, or sterilisation services apply): accountable for the decontamination process (washer disinfectors, autoclaves, traceability records, water-system testing).
• All clinical staff: apply standard infection precautions at every patient encounter (hand hygiene, PPE, aseptic technique, sharps handling, environmental cleaning between patients).
• All staff (clinical and non-clinical): know the basics of IPC at the level the role requires, report any IPC concern to the IPC Lead.

(Tenant updates the named role-holders.)

5. Procedure

The IPC procedure operationalises the ten Code criteria across the service.

1. IPC risk assessment. The IPC Lead maintains an IPC risk assessment for the service: service-user susceptibility (immunocompromised, elderly, paediatric, intoxicated), environmental risks (premises layout, ventilation, water systems), procedural risks (invasive procedures, aerosol-generating procedures, decontamination loads). Reviewed annually and on any change to service shape.
2. Standard infection precautions. Hand hygiene per WHO 5 Moments; PPE per the procedure being performed; aseptic non-touch technique where appropriate; sharps handling per the safer-needles requirements; spillage management; environmental cleaning between patients per the decontamination matrix.
3. Transmission-based precautions. Contact, droplet, and airborne precautions applied when a service user is known or suspected to have a transmissible infection. Isolation facilities used per the service's isolation protocol.
4. Decontamination. Reusable medical devices are decontaminated per Health Technical Memorandum (HTM) 01-01 or equivalent (HTM 01-05 for dental). Decontamination cycles are traceable to the patient where the device was used. Single-use items are not reprocessed.
5. Environmental cleaning, waste and laundry. A cleaning specification names what is cleaned, by whom, at what frequency, and with what product, and it accounts for the particular vulnerabilities and needs of the service-user bands the service supports rather than being a generic schedule. Daily, weekly, and deep-clean cycles are recorded. Clinical and non-clinical waste is segregated, stored, and disposed of safely under the waste regulations, including the safe handling of sharps. Laundry, including uniforms and service-user linen, is handled and decontaminated to prevent cross-infection.
6. Antimicrobial stewardship. Prescribing follows the local antibiotic guidelines, the choice and duration are reviewed at 48 to 72 hours, the audit of antimicrobial use is run quarterly.
7. Service-user and visitor information. Service users are given information about infections relevant to their care (post-procedure infection risk, signs of post-discharge infection, who to contact). Visitor restrictions during outbreaks are communicated clearly.
8. Outbreak management. The IPC Lead declares an outbreak per the Code's threshold; the Outbreak Control Team meets with named attendees from clinical, IPC, management, and (where required) the local Health Protection Team; an outbreak log is maintained; a Reg 18 (Registration Regulations 2009) notification to CQC is filed where the threshold is met.
9. Staff health and wellbeing. Staff with transmissible infections do not work until cleared; occupational-health referral is used where the role-fitness question is more complex; vaccination programmes (seasonal flu, COVID-19 where applicable, hepatitis B, MMR for relevant roles) are operated; and new workers, including those recruited from overseas, have their immunisation status screened and are offered the immunisations their role requires.
10. IPC audit and surveillance. The IPC Lead runs the audit programme per Section 7 below and presents findings at the monthly clinical governance committee.
11. Infection control in people's own homes (domiciliary and supported living). Where the service delivers care in people's own homes, staff assess the infection risks in each home, carry and use the hand-hygiene supplies and PPE they need where home facilities may be limited, handle and dispose of waste (including clinical waste and sharps) safely from the home, and apply standard precautions outside a clinical setting. Because the home is not an environment the service controls, the assessment is done for each home and reviewed.

6. Training requirement

• All staff (clinical and non-clinical) complete IPC awareness training (Level 1) at induction and annually.
• All clinical staff complete IPC practice training (Level 2) at induction and annually, covering hand hygiene, PPE, aseptic technique, sharps handling, environmental cleaning, decontamination, and standard precautions.
• The IPC Lead completes IPC Level 3 (or equivalent specialist) training at appointment and refresher annually.
• The Decontamination Lead (where the role exists) completes decontamination-specialist training at appointment and refresher every two years.

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the IPC Lead:

• Monthly hand-hygiene audit: sampled observations across clinical staff (per the WHO 5-Moments framework or a locally-adapted observation tool).
• Quarterly environmental cleaning audit: sampled cleaning specifications against actual cleaning records, ATP testing where the service uses it.
• Quarterly decontamination audit (where applicable): traceability records reviewed, washer disinfector and autoclave service records checked.
• Annual IPC audit: against the IPC Code of Practice criteria using the IPC audit tool the IPC Lead nominates. Submitted as the annual IPC report.
• Outbreak review (when applicable): after any outbreak, a structured review against the outbreak control protocol, with learning captured as improvement actions.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

IPC records (audit findings, outbreak logs, decontamination traceability records, antimicrobial use audits, IPC risk assessments, staff health records, training records) are held in the tenant's IPC and clinical systems for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. Decontamination traceability records linking a sterilised device to the patient on whom it was used are retained per the patient record (NHS Code of Practice).

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

• Safe Care and Treatment Policy
• Premises and Equipment Policy
• Good Governance Policy
• Statutory Notifications Policy
• Medicines Management Policy

10. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• CQC Regulation 12: Safe care and treatment
• DHSC Health and Social Care Act 2008 Code of Practice on the prevention and control of infections (https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance)
• UKHSA guidance
• NHS England National Infection Prevention and Control Manual
• HTM guidance where healthcare premises (for example HTM 01-01, HTM 01-05, HTM 07-01)
• NHS Records Management Code of Practice
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)

11. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

12. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.